A kia ora, a wave and a smile: an urban marae-led response to COVID-19, a case study in manaakitanga.

BACKGROUND: When COVID-19 emerged, there were well-founded fears that Maori (indigenous peoples of Aotearoa (New Zealand)) would be disproportionately affected, both in terms of morbidity and mortality from COVID-19 itself and through the impact of lock-down measures. A key way in which Kokiri (a Maori health provider) responded was through the establishment of a pataka kai (foodbank) that also provided a gateway to assess need and deliver other support services to whanau (in this case, client). Maori values were integral to this approach, with manaakitanga (kindness or providing care for others) at the heart of Kokiri's actions. We sought to identify how Kokiri operated under the mantle of manaakitanga, during Aotearoa's 2020 nationwide COVID-19 lockdown and to assess the impact of their contributions on Maori whanau. METHODS: We used qualitative methods underpinned by Maori research methodology. Twenty-six whanau interviews and two focus groups were held, one with eight kaimahi (workers) and the other with seven rangatahi (youth) kaimahi. Data was gathered between June and October 2020 (soon after the 2020 lockdown restrictions were lifted), thematically analysed and interpreted using a Maori worldview. RESULTS: Three key themes were identified that aligned to the values framework that forms the practice model that Kokiri kaimahi work within. Kaitiakitanga, whanau and manaakitanga are also long-standing Maori world values. We identified that kaitiakitanga (protecting) and manaakitanga (with kindness) - with whanau at the centre of all decisions and service delivery - worked as a protective mechanism to provide much needed support within the community Kokiri serves. CONCLUSIONS: Maori health providers are well placed to respond effectively in a public-health crisis when resourced appropriately and trusted to deliver. We propose a number of recommendations based on the insights generated from the researchers, kaimahi, and whanau. These are that: Maori be included in pandemic planning and decision-making, Maori-led initiatives and organisations be valued and adequately resourced, and strong communities with strong networks be built during non-crisis times.

He Tamariki Kokoti Tau-Tackling Preterm: a data-linkage methodology to explore the clinical care pathway in preterm deliveries.

BACKGROUND: Significant health inequities exist around maternal and infant health for Maori, the indigenous people of Aotearoa New Zealand - and in particular around a premature (preterm) delivery. Maori babies are more likely to be born preterm (8.1%, compared to an overall rate of 7.4%) and they are more likely to have a preterm death. An essential part of redressing these disparities is to examine the clinical care pathway and outcomes associated with preterm deliveries. This paper describes a protocol utilising national and local health collections to enable such a study. DESIGN: This is a retrospective cohort study comprising 5 years data pertaining to preterm deliveries from 2010 to 2014. These data are generated from linked national administrative and local health information collections to explore a range of neonatal outcomes and infant mortality in relation to the antenatal care pathway and known risk factors for preterm delivery. This study is being conducted within a Kaupapa Maori paradigm that dismisses victim blaming and seeks to intervene at structural levels to improve the health and wellbeing of Maori whanau (family). SIGNIFICANCE OF THE STUDY: Our data-linkage methodology optimises the utility of New Zealand health collections to address a significant health issue. Our findings will fill the information gaps around the burden of preterm delivery by quantifying the incidence of preterm delivery and adverse neonatal and infant outcomes in Aotearoa New Zealand. It will explore access to evidenced based care including use of steroids before birth, and appropriate place of delivery. The results from this study will inform maternity care services to improve management of preterm deliveries - both locally and internationally. This in turn will improve the preterm sequela by reducing the long-term health burden and health inequities.

Mammography service screening and breast cancer mortality in New Zealand: a National Cohort Study 1999-2011.

BACKGROUND: This breast cancer mortality evaluation of service screening mammography in New Zealand, the first since commencement of screening in 1999, applies to the 1999-2011 diagnostic period. Individual-level linked information on mammography screening, breast cancer diagnosis and breast cancer mortality is used to analyse differences in breast cancer mortality according to participation in organised screening mammography, as provided by BreastScreen Aotearoa (BSA). METHODS: Women were followed from the time they became eligible for screening, from age 50 years (1999-2004) and 45 years (⩾2004). Breast cancer mortality from cancers diagnosed during the screening period from 1999 to 2011 (n=4384) is examined in relation to individual screening participation or non-participation during preceding person-years of follow-up from the time of screening eligibility. To account for changes from never- to ever-screened status, breast cancer mortality is calculated for each year in relation to prior accumulated time of participation and non-participation in screening. Breast cancer mortality is also examined in regularly screened women (screened ⩾3 times and mean screening interval ⩽30 months), and irregularly screened women compared with never-screened women. Statistical analyses are by negative binomial and Poisson regression with adjustment for age and ethnic group (Maori, Pacific women) in a repeated-measures analysis. Relative risks for breast cancer mortality compared with never-screened women, are adjusted also for screening selection bias, to indicate the extent of breast cancer mortality reduction in a population offered and not offered mammography screening. Prognostic indicators at diagnosis of breast cancer are also compared between different screening participation groups, including by grade of tumour, extent of disease (spread), multiple tumour status and maximum tumour size using χ2 statistics, t-tests and two-sample median tests. RESULTS: For 1999-2011, after adjusting for age and ethnicity, breast cancer mortality in ever-screened women is estimated to be 62% (95% CI: 51-70) lower than in never-screened women. After further adjustment for screening selection bias, the mortality reduction in NZ is estimated to be 29% (95% CI: 20-38) at an average screening coverage of 64% for 2001-2011, and 34% (95% CI: 25-43) for recent screening coverage (2012-13, 71%). For irregularly screened women, the mortality reduction is estimated to be 31% (95% CI: 21-40), and 39% (95% CI: 22-52) in regularly screened women compared with never-screened women, after adjusting for age, ethnicity and screening selection bias (using recent 2012-2013 screening coverage of 71%). Ever-screened women diagnosed with breast cancer have more favourable prognostic indicators than never-screened women, with a higher proportion of localised cancer (63 compared with 46%), a higher proportion with a well-differentiated tumour (30 compared with 18%), lower risk of multiple tumours (RR=0.48) and smaller median tumour size (15 mm compared with 20 mm)-all differences are statistically significant (P<0.0001). CONCLUSIONS: This is the first total population cohort study of an established nation-wide screening mammography programme using individual-level information on screening participation and mortality outcomes from breast cancer. The findings are in accord with other mammography screening service evaluations and with randomised trials of mammography screening.

Indigenous and tribal peoples' health (The Lancet-Lowitja Institute Global Collaboration): a population study.

BACKGROUND: International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries. METHODS: Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated. FINDINGS: Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations. INTERPRETATION: We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems. FUNDING: The Lowitja Institute.

Uterine cancer: exploring access to services in the public health system.

BACKGROUND: Maori are the indigenous peoples of New Zealand and experience higher rates of uterine cancer and poorer survival rates. Postmenopausal bleeding (PMB) is the most common presenting symptom for uterine cancer. Prompt investigation is essential with 28 days being viewed as an appropriate time from first medical contact (FMC) to first specialist appointment (FSA). AIMS: To compare access to services for the investigation of PMB between Maori and non-Maori women. MATERIALS AND METHODS: The time interval between FMC to FSA was obtained from medical records for women presenting to gynaecology clinics for PMB. Dates of first bleeding symptoms, knowledge and access issues were collected in a nurse-administered questionnaire. RESULTS: A total of 154 women (n = 27 Maori and 127 non-Maori) participated in the study. 23% of women had their FSA from FMC within 28 days and 67% waited more than six weeks. The 75th percentile was approximately two weeks longer for Maori women. 25% (n = 37) of women were not aware that they needed to see a doctor about PMB, and this was significantly more common for Maori women (44%; 95% CI 25-65) than non-Maori women (20%; 95% CI 13-28; P = 0.011). CONCLUSIONS: The majority of women were not seen for FSA within 28 days of their FMC. Maori women were more likely to experience lengthy delays and to report that they did not know they should see a doctor about PMB. Further investigation into reasons for delays and initiatives to improve access to services and health information appears warranted.

Examining the impact of COVID-19 on Maori:non-Maori health inequities in Aotearoa, New Zealand: an observational study protocol.

INTRODUCTION: The COVID-19 pandemic has had both direct and indirect impacts on the health of populations worldwide. While racial/ethnic health inequities in COVID-19 infection are now well known (and ongoing), knowledge about the impact of COVID-19 pandemic management on non-COVID-19-related outcomes for Indigenous peoples is less well understood. This article presents the study protocol for the Health Research Council of New Zealand funded project 'Ma te Mohio ka Marama: Impact of COVID-19 on Maori:non-Maori inequities'. The study aims to explore changes in access to healthcare, quality of healthcare and health outcomes for Maori, the Indigenous peoples of Aotearoa New Zealand (NZ) and non-Maori during the COVID-19 outbreak period across NZ. METHODS AND ANALYSIS: This observational study is framed within a Kaupapa Maori research positioning that includes Kaupapa Maori epidemiology. National datasets will be used to report on access to healthcare, quality of healthcare and health outcomes between Maori and non-Maori during the COVID-19 pandemic in NZ. Study periods are defined as (a) prepandemic period (2015-2019), (b) first pandemic year without COVID-19 vaccines (2020) and (c) pandemic period with COVID-19 vaccines (2021 onwards). Regional and national differences between Maori and non-Maori will be explored in two phases focused on identified health priority areas for NZ including (1) mortality, cancer, long-term conditions, first 1000 days, mental health and (2) rheumatic fever. ETHICS AND DISSEMINATION: This study has ethical approval from the Auckland Health Research Ethics Committee (AHREC AH26253). An advisory group will work with the project team to disseminate the findings of this project via project-specific meetings, peer-reviewed publications and a project-specific website. The overall intention of the project is to highlight areas requiring health policy and practice interventions to address Indigenous inequities in health resulting from COVID-19 pandemic management (both historical and in the future).

Wahine hauora: linking local hospital and national health information datasets to explore maternal risk factors and obstetric outcomes of New Zealand Maori and non-Maori women in relation to infant respiratory admissions and timely immunisations.

BACKGROUND: Significant health inequities exist around maternal and infant health for Maori, the indigenous people of New Zealand. The infants of Maori are more likely to die in their first year of life and also have higher rates of hospital admission for respiratory illnesses, with the greatest burden of morbidity being due to bronchiolitis in those under one year of age. Timely immunisations can prevent some respiratory related hospitalisations, although for Maori, the proportion of infants with age appropriate immunisations are lower than for non-Maori. This paper describes the protocol for a retrospective cohort study that linked local hospital and national health information datasets to explore maternal risk factors and obstetric outcomes in relation to respiratory admissions and timely immunisations for infants of Maori and non-Maori women. METHODS/DESIGN: The study population included pregnant women who gave birth in hospital in one region of New Zealand between 1995 and 2009. Routinely collected local hospital data were linked via a unique identifier (National Health Index number) to national health information databases to assess rates of post-natal admissions and access to health services for Maori and non-Maori mothers and infants. The two primary outcomes for the study are: 1. The rates of respiratory hospitalisations of infants (≤ 1 yr of age) calculated for infants of both Maori and non-Maori women (for mothers under 20 years of age, and overall) accounting for relationship to parity, maternal age, socioeconomic deprivation index, maternal smoking status. 2. The proportion of infants with age appropriate immunisations at six and 12 months, calculated for both infants born to Maori women and infants born to non-Maori women, accounting for relationship to parity, maternal age, socioeconomic deprivation index, smoking status, and other risk factors. DISCUSSION: Analysis of a wide range of routinely collected health information in which maternal and infant data are linked will allow us to directly explore the relationship between key maternal factors and infant health, and provide a greater understanding of the causes of health inequalities that exist between the infants of Maori and non-Maori mothers.

Support for and potential impacts of key Smokefree 2025 strategies among Maori who smoke.

AIM: The recently passed Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act has the potential to profoundly reduce smoking prevalence and related health inequities experienced among Maori. This study examined support for, and potential impacts of, key measures included within the legislation. METHOD: Data came from Wave 1 (2017-2019) of the Te Ara Auahi Kore longitudinal study, which was conducted in partnership with five primary health organisations serving Maori communities. Participants were 701 Maori who smoked. Analysis included both descriptive analysis and logistic regression. RESULTS: More Maori participants supported than did not support the Smokefree 2025 (SF2025) goal of reducing smoking prevalence to below 5%, and the key associated measures. Support was greatest for mandating very low nicotine cigarettes (VLNCs). Participants also believed VLNCs would prompt high rates of quitting. Participants who had made more quit attempts or reported less control over their life were more likely to support VLNCs. CONCLUSION: There was support for the SF2025 goal and for key measures that could achieve it. In particular, VLNCs may have significant potential to reduce smoking prevalence among Maori. As part of developing and implementing these measures it will be important to engage with Maori who smoke and their communities.

Equity of Cancer and Diabetes Co-Occurrence: A National Study With 44 Million Person-Years of Follow-Up.

PURPOSE: The co-occurrence of diabetes and cancer is becoming increasingly common, and this is likely to compound existing inequities in outcomes from both conditions within populations. METHODS: In this study, we investigate the co-occurrence of cancer and diabetes by ethnic groups in New Zealand. National-level diabetes and cancer data on nearly five million individuals over 44 million person-years were used to describe the rate of cancer in a national prevalent cohort of peoples with diabetes versus those without diabetes, by ethnic group (Maori, Pacific, South Asian, Other Asian, and European peoples). RESULTS: The rate of cancer was greater for those with diabetes regardless of ethnic group (age-adjusted rate ratios, Maori, 1.37; 95% CI, 1.33 to 1.42; Pacific, 1.35; 95% CI, 1.28 to 1.43; South Asian, 1.23; 95% CI, 1.12 to 1.36; Other Asian, 1.31; 95% CI, 1.21 to 1.43; European, 1.29; 95% CI, 1.27 to 1.31). Maori had the highest rate of diabetes and cancer co-occurrence. Rates of GI, endocrine, and obesity-related cancers comprised a bulk of the excess cancers occurring among Maori and Pacific peoples with diabetes. CONCLUSION: Our observations reinforce the need for the primordial prevention of risk factors that are shared between diabetes and cancer. Also, the commonality of diabetes and cancer co-occurrence, particularly for Maori, reinforces the need for a multidisciplinary, joined-up approach to the detection and care of both conditions. Given the disproportionate burden of diabetes and those cancers that share risk factors with diabetes, action in these areas is likely to reduce ethnic inequities in outcomes from both conditions.

Analysis of deprivation distribution in New Zealand by ethnicity, 1991-2013.

AIMS: To compare the distribution of Maori and New Zealand (NZ) European populations in Aotearoa New Zealand by neighbourhood deprivation, for the five censuses between 1991 and 2013, and to identify changes in the distribution pattern over time. METHODS: Geographical meshblock data from the 1991-2013 New Zealand censuses, by NZDep Index deprivation score, and by prioritised ethnic group population, were combined to analyse ethnic population counts by deprivation decile and deprivation score. Trends over time were analysed. RESULTS: Maori were over-represented in the more deprived NZDep deciles and under-represented in the least deprived deciles for all census periods. The NZ European population were over-represented in the least deprived deciles, and under-represented in the more deprived deciles. In each census, over 40% of the Maori population have been living in the two most deprived deciles, compared to less than 15% for NZ European. CONCLUSION: The patterns of inequity in socio-economic deprivation between Maori and NZ Europeans have remained virtually unchanged since 1991, despite various Government commitments to reduce inequity. Socio-economic deprivation for Maori is a key determinant of health inequity, and bolder Government measures prioritised for Maori are needed to change this socio-economic gradient if health equity goals are to be met.

Regional variation in post-operative mortality in New Zealand.

BACKGROUND: There is a growing body of evidence that access to best practice perioperative care varies within our population. In this study, we use national-level data to begin to address gaps in our understanding of regional variation in post-operative outcomes within New Zealand. METHODS: Using National Collections data, we examined all inpatient procedures in New Zealand public hospitals between 2005 and 2017 (859 171 acute, 2 276 986 elective/waiting list), and identified deaths within 30 days. We calculated crude and adjusted rates per 100 procedures for the 20 district health boards (DHBs), both for the total population and stratified by ethnicity (Maori/European). Odds ratios comparing the risk of post-operative mortality between Maori and European patients were calculated using crude and adjusted Poisson regression models. RESULTS: We observed regional variations in post-operative mortality outcomes. Maori, compared to European, patients experienced higher post-operative mortality rates in several DHBs, with a trend to higher mortality in almost all DHBs. Regional variation in patterns of age, procedure, deprivation and comorbidity (in particular) largely drives regional variation in post-operative mortality, although variation persists in some regions even after adjusting for these factors. Inequitable outcomes for Maori also persist in several regions despite adjustment for multiple factors, particularly in the elective setting. CONCLUSIONS: The persistence of variation and ethnic disparities in spite of adjustment for confounding and mediating factors suggests that multiple regions require additional resource and support to improve outcomes. Efforts to reduce variation and improve outcomes for patients will require both central planning and monitoring, as well as region-specific intervention.

We still don't count: the under-counting and under-representation of Maori in health and disability sector data.

AIM: To examine ethnicity data quality; in particular, the representation and potential under-counting of Maori in health and disability sector data, as well as implications for inequities. METHODS: Maori and non-Maori ethnicity data are analysed at: 1) a population aggregate level across multiple 2018 datasets (Estimated Resident Population, Census Usually Resident Population, Health Service User (HSU) population and Primary Health Organisation (PHO) enrolments); and 2) an individual level for those linked in PHO and 2018 Census datasets. Ethnicity is drawn from the National Health Index (NHI) in health datasets and variations by age and gender are explored. RESULTS: Aggregate analyses show that Maori are considerably under-represented in HSU and PHO data. In linked analysis Maori were under-counted on the NHI by 16%. Under-representation in data and under-counting occur across both genders but are more pronounced for Maori men with variations by age. CONCLUSION: High quality ethnicity data are fundamental for understanding and monitoring Maori health and health inequities as well as in the provision of targeted services and interventions that are responsive to Maori aspirations and needs. The continued under-counting of Maori in health and disability sector data is a breach of Te Tiriti o Waitangi and must be addressed with urgency.

Mortality after release from incarceration in New Zealand by gender: A national record linkage study.

Background: People who enter and leave places of incarceration experience considerable health inequities and are at increased risk of premature death compared to the general population. Causes of premature death in this population vary markedly between countries and so country-specific information is needed. Additionally, there is a lack of large population-based studies which can disaggregate mortality risk based on person and incarceration factors. This study is the first examination of mortality in the period following release from incarceration in New Zealand. Methods: We linked deidentified administrative data on incarceration and release between 1 January 1998 and 31 December 2016 with national mortality data for the same period to examine mortality after release in those who had been incarcerated for at least 1 day. Age standardised mortality rates and mortality ratios compared to the general New Zealand population were calculated separately for men and women, for releases from remand compared with prison, and by cause of death and time since release. Results: 90,195 individuals (13% women, 49% Maori) were followed up for 9.4 years after release from incarceration, with 4,764 deaths over the follow-up period. The overall standardised mortality ratio was 3.3 (95% CI 3.2, 3.4) compared to the general population, and higher for women (3.8) than men (2.7). The most common causes of death were cardiovascular disease, cancer and suicide. Rates of death were similar following release from remand versus prison, however suicide rates were highest following release from remand. Regardless of the type of incarceration, mortality was highest in the first month after release. Conclusion: Experience of incarceration in New Zealand is associated with high rates of mortality from both chronic conditions and external causes. There are urgent policy imperatives to recognise and actively address the increased health and mortality risks faced by people released from New Zealand prisons.

When personal experience overlaps with study.

BACKGROUND: Health professional education programmes increasingly seek to train a generation of clinicians who reflect the population they serve. However, teaching approaches in health professional education have not always kept pace with this drive, and some educators tend to assume a lack of overlap between students' life experience and aspects of the curriculum. METHOD: In-depth interviews were conducted with 22 health professional students and graduates, who self-identified as having experienced a significant overlap between their personal life and their course of study. These interviews were analysed thematically to explore the role of teaching practices that created either alienating or inclusive learning environments. RESULTS: Participants identified areas where clinical teachers could modify their teaching approach and assumptions about the student cohort to be more inclusive of students whose life experience overlapped with the curriculum. They wanted educators to treat any teaching topic as if it could be personal for some students, which may include teaching inequities carefully, acknowledging family members' perspectives, moderating discussions, and avoiding stereotyping patients. Participants also wanted educators to practice shared decision-making about alternative arrangements or time off. DISCUSSION: Clinical educators have a key role in shaping an inclusive health sciences programme. Their assumptions, attitudes and teaching strategies can either strengthen or undermine the development of a diverse health workforce.

Bowel cancer screening age range for Maori: what is all the fuss about?

The current New Zealand Bowel Screening Programme (BSP) is inequitable. At present, just over half of bowel cancers in Maori present before the age of 60 years (58% in females and 52% in males), whereas just under a third of bowel cancers in non-Maori are diagnosed before the same age (27% in females and 29% in males). The argument for extending the bowel screening age range down to 50 years for Maori is extremely simple-in comparison to non-Maori, a greater percentage of bowel cancers in Maori occur before the age of 60 years (when screening starts). Commencing the BSP at 50 years of age for Maori with high coverage will help fix this inequity. In this paper we review the current epidemiology of colorectal cancer with respect to the age range extension for Maori.